Specialty Rx Use Higher In Exchanges Than Commercial Plans – Express Scripts

Express Scripts analysis of pharmacy claims from the first two months of Affordable Care Act exchange plan operations show members of those plans are prescribed specialty drugs 47% more often than members of commercial plans.

Individuals covered by plans purchased through health care reform’s state insurance exchanges are using high-cost specialty drugs at a much higher rate than those in commercial plans, according to an analysis of early pharmacy claims data by Express Scripts released April 9.

The PBM found that 1.1% of total prescriptions in exchange plans were for specialty drugs, compared to 0.75% for commercial plans, a 47% difference. Specialty drugs are typically far more costly than traditional drugs. Express Scripts’ 2012 Drug Trend Report released April 8 found that while commercial plans’ specialty prescriptions were less than 1% of total scripts, they accounted for nearly 28% of total pharmacy spend (Also see "Specialty Products Top 25% Of Total Rx Spend And Growth To Accelerate – Express Scripts" - Pink Sheet, 8 Apr, 2014.).

The analysis was based on a national sample of more than 650,000 pharmacy claims from Jan. 1 through Feb. 28, 2014 in exchange plans where pharmacy benefits are managed by Express Scripts. That sample was compared to claims from commercial plans with benefits administered by the company during the same period.

Established under the Affordable Care Act, exchange plans first started providing health coverage at the start of the year. While the numbers are still relatively small, this is the first look at drug utilization among their members. Since enrollment in exchange plans continued until March 31, with a surge of new enrollees at the deadline, the patterns could change as those new members begin using their coverage. HHS says 7.1 million people enrolled in exchange plans.

However, the cost data plans receive from early usage will be an important factor as plan sponsors design cost structures for the 2015 coverage year, affecting premiums and cost-sharing. The period for sponsors to submit applications to CMS to sell plans on the federally operated state exchanges for 2015 runs from May 27 to June 27, 2014. This year, 27 state exchanges are operated by the federal government.

Specialty Drugs Are Top Four By Spend

Among the top 10 drugs used by exchange plan members, ranked by total spend, six are specialty drugs, including the top four. The largest drug for exchange plan members by spend is Bristol-Myers Squibb Co./Gilead Sciences Inc.’s HIV medication Atripla (efavirenz/emtricitabine/tenofovir) followed by Gilead’s hepatitis C drug Sovaldi (sofosbuvir). The next two largest are inflammatory disease products, AbbVie Inc.’s Humira (adalimumab) and Amgen Inc.’s Enbrel (etanercept). Also on the list are Gilead’s HIV treatment Truvada (emtricitabine/tenofovir) at number six and Teva Neuroscience Inc.’s multiple sclerosis therapy Copaxone (glatiramer) at nine.

By comparison, only four of the 10 most costly drugs in commercial plans are specialty drugs: Humira (number 1), Enbrel (3), Copaxone (7) and Sovaldi (8).

The relatively high utilization of HIV drugs among exchange plan members is reflected not only in the presence of Atripla and Truvada on the top-spend list, but also in the PBM’s finding that more than six in every 1,000 prescriptions in the exchange plans were for a medication to treat HIV, a proportion nearly four times higher in exchange plans than in commercial health plans.

So far, because exchange plan members have higher cost-sharing and deductible requirements, exchange plan members are covering more of the cost of prescriptions out of pocket compared to their commercial counterparts. As a result, insurers’ per-member pharmacy costs so far this year are 35% higher for commercial plan members compared to exchange plan members. However, as exchange plan members reach their out-of-pocket limits, plans’ expenditures will become greater for those patients.

The report notes that “in order to keep this sustainable and affordable for payers and patients, it’s important to look at the dynamics around deductibles and out-of-pocket maximums, so each group can plan accordingly.”

“We will also be keeping a close eye on cost-shifting and use of the higher-cost tiers for specialty medications and non-preferred drugs, measuring how quickly these exchange enrollees are meeting their out-of-pocket caps, at which point all costs will be on the health insurer. Continued reporting and insights on patient behavior and medication utilization in the exchanges will help our clients provide a competitive, affordable benefit amid the persistent uncertainty common with a new market,” the report says.

Another interesting observation Express Scripts made about the makeup of the exchange plan population is that a large percentage migrated from other plans to the exchange plans, so were previously insured. The PBM said 43% of exchange enrollees were previously enrolled in a plan with Express Scripts in 2013, and the remaining 57% could have been uninsured or previously enrolled in a plan with pharmacy coverage administered by another organization.

Some Differences In Top Classes By Claim Volume

Express Scripts found that, measured by claim volume, many of the drug classes among the top 10 for exchange plan members had similar proportions of total prescriptions as for commercial members, but there were some notable exceptions.

The top two classes in each group, hypertension/heart disease and high blood cholesterol, had similar rates of use, but the number three class, antidepressants, had a 14% higher proportion of total scripts for exchange plan enrollees. Elsewhere on the list, the proportion of pain medications was 35% higher for exchange plan members; the proportion of anti-seizure drugs was 27% higher for exchange plan members; and the proportion of contraceptives was 31% lower for exchange plan members.